Ruminations by a non-academic general surgeon from the heart of the rust belt.

Thursday, August 13, 2009

The $50,000 Gangrenous Foot

This one just takes the cake. We're definitely going to need another Beer Summit after President Obama's latest gaffe:

"If a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's 30,000, 40, $50,000 immediately the surgeon is reimbursed. But why not make sure that we're also reimbursing the care that prevents the amputation? Right? That will save us money."

The ignorant arrogance, it just oozes. Vascular surgeons are getting 50 grand to lop off legs? Interesting. I surely would have done a vascular fellowship if that were the case. Sounds like a gravy train. Sit around, wait for poorly remunerated, overworked primary care docs to neglect the diabetic care of their patients, and boom, one day six of them show up in the office with gangrenous feet. Jackpot!

Listen, amputation is the procedure of last resort. And generally patients don't get referred to vascular surgeons needing amputations. They get referred with rest pain or with ischemic/diabetic ulcers. And then it's a progression of intervention. Conservative care. Stenting. Fem-pop bypass. Revision bypass. Fem-distal bypass. And then, finally, when all else has failed, the patient may need an amputation. And this process is generally managed entirely by the vascular surgeon!

There are those who would say (my least favorite Obama phrase) that our President "simply misspoke". But in the context of his recent remarks on ENT docs whacking out tonsils for financial gain, I tend to think that we're starting to see a pattern. The American College of Surgeons does as well. Once again, we see the President attacking the fragmented physician faction, demonizing us as the primary source of our health care woes. And the way he opted to use leg amputation as an example; chosen randomly out of thin air or a deliberate ploy? There is no more gruesome procedure in surgery than an elective amputation. The imagery and connotation it evokes is powerfully negative--- rich proceduralists hacking off your leg for a cash bonanza. Again, this man does not speak flippantly or off the cuff. Everything is purposeful.

I eagerly await the Great One's clarification of any "misrepresentations".

19 comments:

Anonymous
said...

A patient in New Jersey was billed $72,000 for a spinal fusion procedure that Medicare covers for $1,629 - OR - in California, a patient was charged $20,120 for a knee operation that Medicare pays $584 for. - OR - $6,000 for an ER assessment and three stitches.

The president's point was: medical care payment scale could be widely arbitrary.

Anon-It's wonderful that you are able to infer from the President's remarks what he really meant to say. I'm just a dumb surgeon. All I can do is take his words and sentences at face value. Barack Obama is an intelligent, cunning man. Everything he says or does is purposeful and calculated. This isn't some Sarah Palin spouting word salads. This man knows exactly what he is doing.

Besides, your examples are inappropriate to the task at hand. Obama specifically said that the "vascular surgeon is reimbursed 30 or 40 or 50k". He doesn't imply that the sum represents the total bill for all his pre-hospital, hospital, anesthesia, and facility fees. He says it goes to the vascular surgeon, period. And that's an outright mangling of reality. And that's why his dreams of Obamacare are starting to slip through his fingers.

For whatever it's worth, i agree with you - Obama, being the President, needs to be even more discrete with what he says. He is a politician trying to push a reform through a field that's highly specialized yet contested and broken yet lucrative. Perhaps he is just not as superman-ish (fault-free) as he should have been. I can't imagine any outsider ever be able to quote figures from within our field (or any specialized field) with 100% precision.

The reform is losing momentum because of the fear and distrust (from "socializing" to "death panel" to "losing right to choose") generated by opposing parties.

Given the merit (or lack thereof) of the reform bill itself, should anything Obama say or didn't say make any difference? The noises and distractions are making it increasingly difficult to focus on facts and keep our eyes on the ball. Ultimately, for better or worse, Americans will get to decide the fate of the bill all by ourselves.

Anon-I understand what you're saying about the personal aspects. But you write "The reform is losing momentum because of the fear and distrust (from "socializing" to "death panel" to "losing right to choose") generated by opposing parties".

We have enough problems fending off the lies and distortions of healthcare reform (death panels and the like). For Obama to ramble on about tonsil-scammers and amputation treasure chests only serves to lend credence to those who would willfully distort the truth about what the bill entails. He's screwing it up. And in that respect, as the primary figurehead of healthcare reform, it is all about him....

My chairman at a west coast program was contacted by ABC news and asked for comment. He supplied the actual numbers. Not sure that it ever made it onto the evening news, because it was boring and the truth and whatnot. He also made the point that the few hundred dollars a vascular surgeon makes for an amputation includes hospital time as well as 90 days worth of postop care.

Anon (1:53AM)-I think I'm clearly attacking a very specific trend apparent in the President's healthcare dialogue--- a tendency to distort reality in such a fashion that makes proceduralists and surgeons look like the collective ANti-Christ. To the extent that I am NOT denouncing healthcare reform in general, I fail to see how focusing on this particular aspect represents a "strawman argument".

He said Surgeon and it was clearly his intent to impugn the reputation of doctors. He clearly said that the surgeon would make a choice based on his (he did not say the hospital's) reimbursement. Saying that the surgeon would get $500 for the surgery wouldn't produce the necessary gasp factor. (Random drinker of the Kool-aid: "Oh MY GOD, is THAT what surgeons are paid for an amputation! They are worse than the people on Wall Street who make more than $1m per year. THEY MUST BE STOPPED")

Saying the surgeon would make a decision to amputate based on the profit for the hospital wouldn't make sense, so he didn't say that. There is no slack to cut him here.

The point he was trying to make, that preventative care isn't provided and if it were, we could lower costs, fails on two counts. First - at least in our area -this sort of counseling IS available. We have diabetic classes run by nurses, we have nurses who will teach the patients in the hospital. The patients have access to podiatrists to care for their feet. If they aren't getting this care, it is because they are makingno effort themselves. Perhaps we should have the police round them up and bring them in. Secondly - the concept that preventative care does anything to lower costs is totally fallacious. Some years back, I was in one of my recurrent states of anger over tobacco subsidies, so I did some research to find how much tobacco sales cost us the taxpayer. In fact, and, we SAVE $1 for each pack sold (and this was 20 years ago - probably more like $2.50 now). Why? Because the victims die relatively quickly of cheap diseases - stroke, Lung Ca, MI. Further, they did not collect social security for 20-25 years as they would if they didn't get these diseases. It COSTS us money to make people live longer.

(I would point out that one of our serious financial problems right now is social security and part of the reason that it is a problem is that people are living longer.)

And so it is with other preventative care. It is cheaper to let them get a terminal illness and treat it when it occurs rather than spending money on preventative care and then having them get the terminal illness. You will treat the terminal illness in the same way whenever they get it, but meanwhile you will have spent more $ for this preventative care.

Of course this presumes that preventative care does anything at all to prolong life. I might buy it for mammography, but that is a small effect when looked at in terms of the whole population. And that is not preventative, simply early detection. I would have to see someone produce proof that preventative care is in any way effective for anything other than spending money.

Of course, the phrase "preventative care" is useful for politicians to use to sound as if they care.

Whoa! Where do vascular surgeons do amputations? Around here, they refer them back to either general surgery or ortho, so that procedure must be beneath them.

As for Obama: I suppose it is possible that he mistook the total cost of the procedure (hospital, imaging, anesthesia, etc.) as just the surgeon's fee. Then again, as you say, he is no Sarah Palin, so I admit there is the distinct possibility that this and his other egregiously wrong statements (re: tonsils) may have more sinister underpinnings. Unlike some, though, I refuse to rush to judgment and await further developments, whereupon I reserve the right to change my opinion of him.

I imagine he's maligning physicians and surgeons in order to paint them as greedy bastards. That way it'll be easier to slash medicare rates after the huge public plan completely undermines any possible competition. The large number of patients enrolled will mean unbelievable strength collective bargaining.

There was a video of Obama stating that he wanted to eliminate private insurance in the long term... I'm in the library, so I can't go looking for it.

"...an estimated three-quarters of people who are pushed into personal bankruptcy by medical problems actually had insurance when they got sick or were injured." *

Just what's so amazing about America's insurance [coverage]? They are among the top driving forces behind US health care cost spiral. They dictate everything from what and who get covered or denied, malpractice premium, bureaucratic definitions of medical conditions, research finding suppression & discrimination, etc.

Are you sure you really want to entrust the future and autonomy of your entire medical establishment to a handful of profit calculators?

How can anyone believe this is NOT about him? He is out to save the world and step one is to find someone to demonize-in this case it is greedy doctors-individuals whose every waking moment is focused on the most lucrative billable option and that must be stopped and stopped "this year" (19 weeks left folks)

Once he has people convinced that he and ONLY he can save them, they will annoint him (again) as savior-a title I think he finds more suiting than President. After all there have been 43 other presidents, but oh so few saviors.

His promises are hallow-watch what he does. " Example: Promise:I will give a you a transparent Washinton DC Action: ~ 20 czars appointed most of which not subject to Senate confirmation AND their salaries/duties/accountabilities are whatever the Savior wants them to be.

This guy does not "mis-speak". Everything he says links to a plan-that is the purpose of the teleprompter-to keep him on message. Look what happens to him when the teleprompter fails-uh..uh... well. uh. His comments (no teleprompter)about DC police acting stupidly-even as he admitted he did not have the facts, reflect his true beliefs.

He got called on it (Joe the Cop) -got caught- and arranged a "beer summit" to resolve what-that he is sorry that people did not understand him or he is concerned that people did? BTW drop the phony rolled-up sleeve, relate to the working man crap. It is insulting.

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